Case Report 38 4
Abdominal Aortic Aneurysm Repair After Renal Transplantation with Extracorporeal Bypass w
Wolf, K. Ayisi. MiIsmail, P Kalmar. H. Pekar ", and S. Trautwein** Depar ment ofThoracic- and Cardiovascular-Surgery * Departm ent ofAnaesthesiology ** Department of Urology, University Hospital, Hamburg, Germany
The successfu l resection of an abdominal aortic aneurys m is prese nted in a pati ent who had und ergone kidney tran splantation 4 yea rs previously. Becaus e th e transplant ed kidn ey is mor e sensitive to ischemia than a no rmal one, a femoro-femoral bypass with a pump oxygenator was used for perfusion of th e transplanted kidney during cross clamping. During the clamp ing time of 40 min utes kidn ey perfusion was maintained with a perfusion pr essure of 60 to 80 mmHg a nd the flow was 600 to 1000mVmin. A collagen -seed ed Dacron graft (diame ter: 18 mm , length: 12 mrn) was interp osed . Th e postoperative course was un compli cat ed . We believe that performing the fernoro-femo ra l bypass with a pump oxygena tor is a n effective a nd simple meth od for kidn ey protection in such operations. Keywords
Die Behandlung des infrarenalen Baucha ortenaneurysma nach Nie re ntrans pla nta tion Es wird tiber einen 51jiihrigen Patient en beri chtet, bei dem 4 Jahre nach Nierentranspla ntation ein infr ar en ales Bauchaorten an eurysma operie rt wurde. Da die Transplantatniere in besond erem Malle ischiimi egefiihrd et ist , benutzten wir eine n femoro-femoralen Bypass mitt els HLM als Isch iimieschutz. Wiihrend der 40mintitigen Abklemm zeit wurde die Transplan tatniere mit Druckwertenzwischen 60 und 80 mmHg perfun diert, der dazu erforde rliche FluB lag zwischen 600 und 1 OOOmVmin. Eine Kollagenb es chicht ete Dacron-Rohrprothese (18mm x 12 cm) wurde einges etzt. Der postop erati ve Verlauf wa r unkomplizi ert . Wir halten den femo ro-femoralen Shunt mitt els HLM fur eine wirks am e und einfache Methode zum Ischami eschut z der Tran splantatni er e bei der artigen Oper ation en.
Abdomina l aortic an eurysm - Ane urys m surgery - Kidney tran sp lantati on - Kidney pr otection
Introduction
Operative Procedu re
Surgica l managemen t of an abd ominal aneurysm in pa tients with a tra nsplan ted kidney has rarely been report ed (1-9) . This article describes the successful opera tion of an abdomina l aortic aneurysm in such a patient with the use of an extracorporeal circuit for kidney pr otection during aortic crossclamping.
In May 1990 the pati ent und erw ent elective surgery of the an eurysm. After induction of a neurolept a nesthesia , lap arotomy was performed thro ugh a midlin e incision. Following exploration of th e abdomen the aneurysm was expos ed . To avoid endangering th e transplanted kidney as a resu lt of ischemia du e to the aortic clamping, it was decided to perform a femoro-fernoral bypass using a pump-oxygenator to perfuse the iliac region including the transplanted kidn ey. 1200ml ofRing er's lactate wa s used as the priming fluid for th e pump oxygenator. Before we clamp ed the ao rta proximally and th e common iliac arteries below th e bifur cati on , we heparinized th e patien t at a dosage of 300 un its/k g body weight. Kidn ey perfusi on was maintained with a perfu sion pressure of 60 to 80 mmH g a nd a flow of6 00 to 1000 mVmin. The a neurys mat ic par t of the aorta was rep laced with a collagen-seeded Dacron graft of diameter 18 mm a nd length 12 ern (Gelseal, Vascutec). During surger y urin e output was normal, the hematocrit level was maint ain ed at 30 to 32%. Aortic clamping last ed 40 minutes. Th e intraoper at ive blood loss of 1100ml was retr ansfused usin g a cell-sa ver.
Case Report A 5 1-yea r-old mal e pati ent , 93 kg body weight and 171 cm in height, developed ac ute myocardial infarction in February 1980 a nd in November of that year und erw ent surgery for corona ry heart disease. Chro nic glome rulone phritis had been diagnosed ten yea rs ea rlier. Th e pati ent was then put on hem odialysis until August 1986. whe n a kidn ey tr ansplantation was perform ed in the left iliac foss a. To control the rejection reactions, three immunosuppress ive agents were used , namely Cyclosp orin A (dose calculated acco rdi ng to serum levels), Immur ek (25 mgl.and Predn ison (25 mg). Durin g a routine exa mina tion of th e a bdome n a n infra rena l abd omin al ao rtic an eurysm was disc over ed. Computerise d axial tom ography sh owed a n an eurysm of 6 cm in diam eter and 12 cm in len gth, and th e iliac a rteries were normal. Risk factors were a rterial hypert en sion and hyperlipop rot eina em ia.
Thora c. cardiovasc. Surgeon 39 (1991) 384- 385 © Georg Thieme Verlag Stuttgar t · New York
Received for Publi cation: May 27, 1991
Downloaded by: Universite Laval. Copyrighted material.
Summa ry
Fig. 1 CT scan ofabdominal aortic aneurysm of a 51-year-old patientafter kidney transplantation
Fig.2 Transfemoral perfusionfor oxygen supplyofthe kidney witha pumpoxygenator duringthe clampingperiod
Thora c. cardiavase. S urge on 39 (1991)
tection are available, One of the se methods involves th e use of an aortoiliacal bypass with a Gatt (4) or a fabric graft (7) shunt. But the proximal anastomosis of the shunt can be difficult wh en the healthy segment of the infrarenal aorta is short. Moreover , preparation of the iliac artery for th e distal anastomosis in an area wh ere adhesions following kidn ey transplantation occur can damage th e transplant. Another method of intraoperative kidn ey protection involves perfusion of th e transplanted kidn ey with a cold Ringer's lactate solution (6) intraoperatively. Shons (8) and Sterioff(9) used an axillo-femoral bypass for th e perfusion and protection of the kidn ey. In our opinion, the use of a temporary shunt could prov e to be risky , Ther efore we pr eferred to us e a femoro-femoral bypass employing a pump oxygenator for kidney protection. This method can be used ea sily in a cardiovascular unit, where use of ECC is routine . In our cas e, ECC perfusion of th e transplanted kidney was regulated by pump-pressure (60-80mmHg) , because we could not estimate the volum e which flowed into the int erna iliac artery region. Judging by th e reports in the literature (2, 3) and our experi enc e, we believe that performing the femorofemoral bypass using a heart lun g machine is an effective and simple method for kidne y protection in such operations.
References I
2
3
4
Postoperative Course Th e pat ient was extu ba te d on th e da y of ope ra tion , sho wing good gas exc hange , stable hemodyn amic cond itions, a nd a sin us rhythm . Following d iuret ic ther ap y urin e output w as normal. Despite a no rm al urin e output , th e serum cre a tin ine in cr ea sed postoperatively to 4 mg/dl but th en r eturned qu ickly to n ormal lev els. Oral nutriti on w as resumed on th e third postop erative day wi th th e onset of normal bo w el m ovem ent. No wound com plica tio ns were observe d. An ultrasoni c exa mi natio n of th e kidn ey on the fifth p ost op erati ve da y r eveal ed no parenchymal defect of th e tr ansplanted kidney.
5 6
7
8
9
Boudr eaux, J. P., F. J. Wolma, and J. C. Fish: Abd ominal Aortic Aneury sm Repair after Renal Tra nsplantation with out Extrac orporeal Bypass . Tra nsplantation Proceedi ngs . Vol. 22 , No. 2 (1990) 40 3 Campell. D. A. . M. I. Lorber. W. A. A rneso n, M. N. Kirsh, J. G. Turcott e, and J. C. Stanley: Renal Transplant Protection During Abdomina l Ane urysmect omy with a Pump-Oxygen ator. Surger y 90 (1981) 559 Gibbons, G. w., P. N. Madra s, F. C. Wheelock, A. l. S ahyoun, a ndA. P. Manoca: Aortoiliac Recons tru ction Following Ren al Tra nsp la nta tion . Surge ry 91 (1982) 435 Got t, V. L.: Heparinized Shunts for Thoracic Vascular Oper ati ons. Ann.Thorac . Surg. 14(197 2) 219 Lacombe, M.: Abdominal Aortic Ane urys mecto my in Renal Transplant Patients. Ann. Surg. 203 (1986) 62 Nus saume, 0 ., J. C. Couffi nhal. L. Moulonqu ei-Doleris, et al.: Cure d'un ane urys me de l'aorte abdomin ale en am ont d'u n ae in tr ansplant e. Presse Med. 12 (1983) 1537 O'Mcra, Ch. 5.. W. R. Flinn, J. J. Bergan. a nd J. S. T Yao: Use of Tempora ry Shun t for Renal Tra ns plant Protec tion during Aortic Aneurys m Repair. Surger y 94 (1982) 512 Sh ons. A. R., C.5. De Sh azo, L. Ra tt azzi, a nd J. S. Naja rian: Ren al Tra ns plantation with Blood Supply by Axillo-femora l Bypass Graft. Am. J. Surg. 132(19 76)9 7 St erioff, 5. . and L. Parks : Tempo rary Vascular Bypa ss for Perfusion of a Ren al Tra nsplant during Abdomi na l Aneurysmec tomy. Surger y 82 (197 7) 558
Discussion
Priu. Doz. Dr. W. Wolf
Surgical management of su ch patients as in this cas e using extracorpore al circulation (ECC) has seldom been reported (1-9). It is assume d that a transplanted kidney is more sensitive to ischemia than a normal one. Several methods of providing intraoperative kidney perfu sion and henc e pro-
Department of Thoracic- and Cardiovascular Surg ery Univers ita ts-Kra nkcnhaus Hamburg-Eppendorf MartinistraBe 52 0 -2000 Hamburg 20 Germa ny
385
Downloaded by: Universite Laval. Copyrighted material.
A bdom ina l A ortic A ne urys m Repair Af te r Renal Tran splantation with Ex tra corporea l Bypass
Abdominal Aortic Aneurysm Repair After Renal Transplantation with Extracorporeal Bypass w
Wolf, K. Ayisi. MiIsmail, P Kalmar. H. Pekar ", and S. Trautwein** Depar ment ofThoracic- and Cardiovascular-Surgery * Departm ent ofAnaesthesiology ** Department of Urology, University Hospital, Hamburg, Germany
The successfu l resection of an abdominal aortic aneurys m is prese nted in a pati ent who had und ergone kidney tran splantation 4 yea rs previously. Becaus e th e transplant ed kidn ey is mor e sensitive to ischemia than a no rmal one, a femoro-femoral bypass with a pump oxygenator was used for perfusion of th e transplanted kidney during cross clamping. During the clamp ing time of 40 min utes kidn ey perfusion was maintained with a perfusion pr essure of 60 to 80 mmHg a nd the flow was 600 to 1000mVmin. A collagen -seed ed Dacron graft (diame ter: 18 mm , length: 12 mrn) was interp osed . Th e postoperative course was un compli cat ed . We believe that performing the fernoro-femo ra l bypass with a pump oxygena tor is a n effective a nd simple meth od for kidn ey protection in such operations. Keywords
Die Behandlung des infrarenalen Baucha ortenaneurysma nach Nie re ntrans pla nta tion Es wird tiber einen 51jiihrigen Patient en beri chtet, bei dem 4 Jahre nach Nierentranspla ntation ein infr ar en ales Bauchaorten an eurysma operie rt wurde. Da die Transplantatniere in besond erem Malle ischiimi egefiihrd et ist , benutzten wir eine n femoro-femoralen Bypass mitt els HLM als Isch iimieschutz. Wiihrend der 40mintitigen Abklemm zeit wurde die Transplan tatniere mit Druckwertenzwischen 60 und 80 mmHg perfun diert, der dazu erforde rliche FluB lag zwischen 600 und 1 OOOmVmin. Eine Kollagenb es chicht ete Dacron-Rohrprothese (18mm x 12 cm) wurde einges etzt. Der postop erati ve Verlauf wa r unkomplizi ert . Wir halten den femo ro-femoralen Shunt mitt els HLM fur eine wirks am e und einfache Methode zum Ischami eschut z der Tran splantatni er e bei der artigen Oper ation en.
Abdomina l aortic an eurysm - Ane urys m surgery - Kidney tran sp lantati on - Kidney pr otection
Introduction
Operative Procedu re
Surgica l managemen t of an abd ominal aneurysm in pa tients with a tra nsplan ted kidney has rarely been report ed (1-9) . This article describes the successful opera tion of an abdomina l aortic aneurysm in such a patient with the use of an extracorporeal circuit for kidney pr otection during aortic crossclamping.
In May 1990 the pati ent und erw ent elective surgery of the an eurysm. After induction of a neurolept a nesthesia , lap arotomy was performed thro ugh a midlin e incision. Following exploration of th e abdomen the aneurysm was expos ed . To avoid endangering th e transplanted kidney as a resu lt of ischemia du e to the aortic clamping, it was decided to perform a femoro-fernoral bypass using a pump-oxygenator to perfuse the iliac region including the transplanted kidn ey. 1200ml ofRing er's lactate wa s used as the priming fluid for th e pump oxygenator. Before we clamp ed the ao rta proximally and th e common iliac arteries below th e bifur cati on , we heparinized th e patien t at a dosage of 300 un its/k g body weight. Kidn ey perfusi on was maintained with a perfu sion pressure of 60 to 80 mmH g a nd a flow of6 00 to 1000 mVmin. The a neurys mat ic par t of the aorta was rep laced with a collagen-seeded Dacron graft of diameter 18 mm a nd length 12 ern (Gelseal, Vascutec). During surger y urin e output was normal, the hematocrit level was maint ain ed at 30 to 32%. Aortic clamping last ed 40 minutes. Th e intraoper at ive blood loss of 1100ml was retr ansfused usin g a cell-sa ver.
Case Report A 5 1-yea r-old mal e pati ent , 93 kg body weight and 171 cm in height, developed ac ute myocardial infarction in February 1980 a nd in November of that year und erw ent surgery for corona ry heart disease. Chro nic glome rulone phritis had been diagnosed ten yea rs ea rlier. Th e pati ent was then put on hem odialysis until August 1986. whe n a kidn ey tr ansplantation was perform ed in the left iliac foss a. To control the rejection reactions, three immunosuppress ive agents were used , namely Cyclosp orin A (dose calculated acco rdi ng to serum levels), Immur ek (25 mgl.and Predn ison (25 mg). Durin g a routine exa mina tion of th e a bdome n a n infra rena l abd omin al ao rtic an eurysm was disc over ed. Computerise d axial tom ography sh owed a n an eurysm of 6 cm in diam eter and 12 cm in len gth, and th e iliac a rteries were normal. Risk factors were a rterial hypert en sion and hyperlipop rot eina em ia.
Thora c. cardiovasc. Surgeon 39 (1991) 384- 385 © Georg Thieme Verlag Stuttgar t · New York
Received for Publi cation: May 27, 1991
Downloaded by: Universite Laval. Copyrighted material.
Summa ry
Fig. 1 CT scan ofabdominal aortic aneurysm of a 51-year-old patientafter kidney transplantation
Fig.2 Transfemoral perfusionfor oxygen supplyofthe kidney witha pumpoxygenator duringthe clampingperiod
Thora c. cardiavase. S urge on 39 (1991)
tection are available, One of the se methods involves th e use of an aortoiliacal bypass with a Gatt (4) or a fabric graft (7) shunt. But the proximal anastomosis of the shunt can be difficult wh en the healthy segment of the infrarenal aorta is short. Moreover , preparation of the iliac artery for th e distal anastomosis in an area wh ere adhesions following kidn ey transplantation occur can damage th e transplant. Another method of intraoperative kidn ey protection involves perfusion of th e transplanted kidn ey with a cold Ringer's lactate solution (6) intraoperatively. Shons (8) and Sterioff(9) used an axillo-femoral bypass for th e perfusion and protection of the kidn ey. In our opinion, the use of a temporary shunt could prov e to be risky , Ther efore we pr eferred to us e a femoro-femoral bypass employing a pump oxygenator for kidney protection. This method can be used ea sily in a cardiovascular unit, where use of ECC is routine . In our cas e, ECC perfusion of th e transplanted kidney was regulated by pump-pressure (60-80mmHg) , because we could not estimate the volum e which flowed into the int erna iliac artery region. Judging by th e reports in the literature (2, 3) and our experi enc e, we believe that performing the femorofemoral bypass using a heart lun g machine is an effective and simple method for kidne y protection in such operations.
References I
2
3
4
Postoperative Course Th e pat ient was extu ba te d on th e da y of ope ra tion , sho wing good gas exc hange , stable hemodyn amic cond itions, a nd a sin us rhythm . Following d iuret ic ther ap y urin e output w as normal. Despite a no rm al urin e output , th e serum cre a tin ine in cr ea sed postoperatively to 4 mg/dl but th en r eturned qu ickly to n ormal lev els. Oral nutriti on w as resumed on th e third postop erative day wi th th e onset of normal bo w el m ovem ent. No wound com plica tio ns were observe d. An ultrasoni c exa mi natio n of th e kidn ey on the fifth p ost op erati ve da y r eveal ed no parenchymal defect of th e tr ansplanted kidney.
5 6
7
8
9
Boudr eaux, J. P., F. J. Wolma, and J. C. Fish: Abd ominal Aortic Aneury sm Repair after Renal Tra nsplantation with out Extrac orporeal Bypass . Tra nsplantation Proceedi ngs . Vol. 22 , No. 2 (1990) 40 3 Campell. D. A. . M. I. Lorber. W. A. A rneso n, M. N. Kirsh, J. G. Turcott e, and J. C. Stanley: Renal Transplant Protection During Abdomina l Ane urysmect omy with a Pump-Oxygen ator. Surger y 90 (1981) 559 Gibbons, G. w., P. N. Madra s, F. C. Wheelock, A. l. S ahyoun, a ndA. P. Manoca: Aortoiliac Recons tru ction Following Ren al Tra nsp la nta tion . Surge ry 91 (1982) 435 Got t, V. L.: Heparinized Shunts for Thoracic Vascular Oper ati ons. Ann.Thorac . Surg. 14(197 2) 219 Lacombe, M.: Abdominal Aortic Ane urys mecto my in Renal Transplant Patients. Ann. Surg. 203 (1986) 62 Nus saume, 0 ., J. C. Couffi nhal. L. Moulonqu ei-Doleris, et al.: Cure d'un ane urys me de l'aorte abdomin ale en am ont d'u n ae in tr ansplant e. Presse Med. 12 (1983) 1537 O'Mcra, Ch. 5.. W. R. Flinn, J. J. Bergan. a nd J. S. T Yao: Use of Tempora ry Shun t for Renal Tra ns plant Protec tion during Aortic Aneurys m Repair. Surger y 94 (1982) 512 Sh ons. A. R., C.5. De Sh azo, L. Ra tt azzi, a nd J. S. Naja rian: Ren al Tra ns plantation with Blood Supply by Axillo-femora l Bypass Graft. Am. J. Surg. 132(19 76)9 7 St erioff, 5. . and L. Parks : Tempo rary Vascular Bypa ss for Perfusion of a Ren al Tra nsplant during Abdomi na l Aneurysmec tomy. Surger y 82 (197 7) 558
Discussion
Priu. Doz. Dr. W. Wolf
Surgical management of su ch patients as in this cas e using extracorpore al circulation (ECC) has seldom been reported (1-9). It is assume d that a transplanted kidney is more sensitive to ischemia than a normal one. Several methods of providing intraoperative kidney perfu sion and henc e pro-
Department of Thoracic- and Cardiovascular Surg ery Univers ita ts-Kra nkcnhaus Hamburg-Eppendorf MartinistraBe 52 0 -2000 Hamburg 20 Germa ny
385
Downloaded by: Universite Laval. Copyrighted material.
A bdom ina l A ortic A ne urys m Repair Af te r Renal Tran splantation with Ex tra corporea l Bypass
